1396746525 NPI number — CKC MEDICAL INC

Table of content: (NPI 1396746525)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396746525 NPI number — CKC MEDICAL INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CKC MEDICAL INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396746525
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25671 FORT MEIGS RD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
PERRYSBURG
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43551-1191
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-872-4775
Provider Business Mailing Address Fax Number:
419-872-4776

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25671 FORT MEIGS RD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
PERRYSBURG
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43551-1191
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-872-4775
Provider Business Practice Location Address Fax Number:
419-872-4776
Provider Enumeration Date:
08/10/2005

Additional Information

Authorized Official

Authorized Official Last Name:
NNAJI
Authorized Official First Name:
IBE
Authorized Official Middle Name:
U
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
419-872-4775

Provider Taxonomy Codes

  • Taxonomy code: 332BP3500X , with the licence number:  HMER 22028 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , with the licence number: HMER 22028 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2015018 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0000002498007 . This is a "ANTHEM BCBS MANSFIELD" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000249807 . This is a "ANTHEM BCBS PERRYSBURG" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 8700304 . This is a "INDIVIDUAL OPTIONS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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